The patient who abuses alcohol often is in denial about his addiction and frequently becomes unruly and obstinate as necessary detox measures and treatments are carried out. When the patient is elderly, additional issues can come into play, such as dementia and a poorly functioning immune system caused by years of drinking.

Increasing Numbers

Unfortunately, caring for elderly alcoholics is not an uncommon challenge. Studies find an increasing prevalence of alcoholism among older adults in health care settings.1 In fact, surveys show 6-11 percent of elderly people admitted to hospitals have symptoms of alcoholism, as do 20 percent in psychiatric wards and 14 percent in emergency departments.¹

Alcohol-related admission rates to acute care hospitals also have been found to be similar to those for myocardial infarction, and evidence shows the prevalence of problem drinking in nursing homes is as high as 49 percent.¹

Alcoholism itself can be a major concern, but when combined with medical problems associated with aging, care and treatment issues often are compounded. For instance, alcohol consumption causes more falls involving hip fractures in the elderly than would otherwise occur, due to their decreased bone density compared to elderly nonalcoholics.¹

Elderly drivers who have consumed alcohol are at greater risk for accidents; with age it takes less alcohol to interfere with coordination, judgment and medications.²

Increased medication use and age-related liver degeneration means that older adults' bodies cannot break down the drugs and eliminate them as quickly; this puts them at more risk to suffer adverse reactions.² The heart, gastrointestinal tract, immune system and cognitive and motor functions of the brain also are negatively affected by alcohol consumption, and it has been found to increase the risk for some cancers.²

Subtle Symptoms

Regardless of age, caring for a patient with alcoholism is a challenge. Unless someone reports the ED patient is an alcoholic, staff often have to look for subtle symptoms, according to Catherine Wilson, RN, a psychiatric nurse clinician at Virginia Commonwealth University Hospital, Richmond. "Most patients are not going to come to you and say they drink every day," she said.

When a patient shows up in the ED with a fractured hip, sky-high blood alcohol level and is taking out his hostilities on caregivers, the important thing is to keep him from going into withdrawal, Wilson said. Symptoms of this can be a rising temperature, tremors, nausea and vomiting.

With the elderly, these syptoms can mean the patient may be deteriorating rapidly. He can go into delirium tremens, including hallucinations, as well as develop other symptoms-seizures, coma and even death. "People do die from alcohol withdrawal," Wilson emphasized.

Decision Time

In the ED, many elderly alcoholic patients require surgery after a fall. The attending physician must decide what should come first, the surgery or detoxification. The anesthesiologist, in fact, may make the call to detox first, based on lab results showing magnesium deficiency and/or other abnormal values.

"Obviously, the risks of postponing any surgical intervention must be weighed against the risks of undergoing surgery," said William J. Lorman, PhD, MSN, PsyNP, CARN-AP, chief clinical officer at Livengrin Foundation in Bensalem, PA, a facility caring for those requiring intervention due to alcohol or drug abuse.

Detox Measures

Wilson stressed, "There is a very fine balance with the elderly, because they tend to react to benzodiazepines [e.g., lorazepam, a commonly used detox drug], more than younger adults. Sometimes phenobarbitol is used instead."

ED staff also must look for comorbidities such as high blood pressure and other sequelae that tend to accompany prolonged alcohol use.

"If surgery is urgent, the use of benzodiazepines will prevent withdrawal for up to 14 days," Lorman said.

"Interestingly," he noted, "the complications reported postoperatively are not secondary to alcohol withdrawal itself, but instead are related to infection, bleeding and delayed wound healing as a result of chronic alcohol misuse."

References available at www.advanceweb.com/OT or upon request.

Bette Mooney is a freelance writer and retired editor at ADVANCE.